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    <title>Auto - Claims</title>
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      $("#useGPS").button({icons :{primary : "ui-icon-circle-plus"}});
      $("#recordAudio").button({icons :{primary : "ui-icon-volume-on"}});
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      $("#submitClaim").button({icons :{primary : "ui-icon-circle-check"}});
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    <ul>
      <li class="header propertyHeading">2010 NISSAN QUEST 3.5 BASE/S/SL/SE <div style="font-size: .6em;"><span class="label">VIN:</span> <span>5N1BV28U76N109091</span></div></li>

        <ul class="list">
              
          
          <li class="item" style="padding-top: 20px;">
            <ul>
              <li><span class="_property"></span><span class="largeLabel">Claim information</span></li>

              <form id="paymentForm">
                <fieldset>
                  <div class="formRow">
                    <label for="dateOfLoss" >Date of loss </label> 
                    <input type="date" name="dateOfLoss" id="dateOfLoss" placeholder="mm/dd/yy"/> 
                  </div>
                  <div class="formRow">                    
                    <label  for="payOtherAmount">How many vehicles were involved</label> 
                    <select id="numVehicles">
                      <option></option>
                      <option>1</option>
                      <option>2</option>
                      <option>3</option>                      
                    </select>
                  </div>

                  <div class="formRow">                    
                    <label  for="accidentDescription" >What best describes your accident</label> 
                    <select id="numVehicles">
                      <option></option>
                      <option>Single vehicle accident or hit and run</option>
                      <option>Collision with animal</option>
                      <option>Flood or hail damage</option>
                      <option>Total theft of vehicle</option>                  
                    </select>
                  </div>     
                  
                  <div class="formRow">                    
                    <label  for="location">Where did the accident occur?</label> 
                    <input type="text" id="location" name="location"/>
                    <button id="useGPS">Use GPS location</button>
                  </div>       
                  
                  <div class="formRow">                    
                    <label >Is the vehicle being repaired in the state the loss occurred?</label> 
                    <input type="radio" id="lossStateYes" name="lossState" value="Yes" /><label class="inline">Yes</label> 
                    <input type="radio" id="lossStateNo" name="lossState" value="No" /><label class="inline">No</label> 
                  </div>                         

                  <div class="formRow">                    
                    <label >Is the vehicle driveable?</label> 
                    <input type="radio" id="driveableYes" name="driveable" value="Yes" /><label class="inline">Yes</label> 
                    <input type="radio" id="driveableNo" name="driveable" value="No" /><label class="inline">No</label> 
                  </div>                                           
                  
                  
                  <div class="formRow">
                    <label for="detailedDescription">Explain what happened</label>
                    <textarea name="detailedDescription" id="detailedDescription" rows="5" cols="30"></textarea>
                  </div>
                  
                  <div class="formRow">
                    <label for="attachPhotos">You may take photos with your camera to attach to your claim</label>
                    <button id="attachPhotos">Attach photos</button>
                  </div>                       
                  
                  <div class="formRow">
                    <label for="recordAudio">You may record audio statements from eye witnesses or police officers on the scene</label>
                    <button id="recordAudio">Record audio</button>
                  </div>                  
                  
                  
                  <div class="formRow" style="margin-top: 20px;">
                    <button id="submitClaim">Submit claim</button>
                  </div>
                  
                </fieldset>
              </form>
              
            </ul>
          </li>                 

            </ul>
          </li>

    </ul>

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